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Based on record record and interview, the facility failed to protect patient rights to be free from abuse/harassment and from subsequent episodes of misconduct for 1 of 1 Patients (Pt. #1) and all patients on the Medical Surgical/Intensive Care Unit (MSICU), and the facility failed to initiate/conduct a timely investigation as a result of facility staff (RN F and RN G) not making an immediate report of abuse after witnessing 1 of 1 incidents involving RN A and Pt. #1 in a sample of 1 caregiver misconduct investigations reviewed.

Findings:

Facility staff (RN F and RN G) failed to report an incident of abuse immediately immediately after witnessing 1 of 1 incidents involving RN A per facility policy. See Tag A-0145

The facility failed to initiate/conduct a timely investigation as a result of facility staff (RN F and RN G) not making an immediate report of abuse after witnessing 1 of 1 incidents involving RN A. See Tag A-0145.

The facility failed to protect patients from further abuse when RN A continued to provide direct patient care for multiple shifts due to failure of staff (RN F and RN G) to immediately report an abuse incident involving RN A. See Tag A-0145.

Based on record record and interview, the facility failed to protect patient rights to be free from abuse/harassment and from subsequent episodes of misconduct for 1 of 1 Patients (Pt. #1) and all patients on the Medical Surgical/Intensive Care Unit (MSICU), and the facility failed to initiate/conduct a timely investigation as a result of facility staff (RN F and RN G) not making an immediate report of abuse after witnessing 1 of 1 incidents involving RN A and Pt. #1 in a sample of 1 caregiver misconduct investigations reviewed.

Findings include:

A review of the Misconduct Incident Report (MIR) submitted by Clinical Risk Management D on 08/01/2023 at 11:57 AM revealed,"...Date occurred 07/25/2023 Time occurred 03:00 PM Is occurred date and time estimated? Yes Date discovered 07/31/2023 Briefly describe the incident...An RN was attempting to place ultrasound IV on patient. The patient had been pulling at lines and tubes, confused, and disorientated to time and situation. The patient was agitated. The RN grabbed the patients shoulder hard enough that the patient was visibly in pain. After a short time, the RN released the patient's shoulder, and the second RN was able to verbally redirect the patient until RN placing the IV was able to poke the patient with IV needle. As the patient was poked, he screamed again and pulled his arm back, at that time RN grabbed near patient's armpit and pinched, again inflicting pain. A third time the RN placing the IV took his finger and poked into the patient's rib cage causing the patient to react in pain."

A review of the facility policy, titled "Reporting and Investigating Caregiver Misconduct Policy & Procedure (System)", last revised 12/2020, revealed: "...The immediate reporting of alleged or actual mistreatment, neglect, or abuse to any patient, is essential to ensure the highest quality of patient care and safety...RESPOND AND REPORT...Immediately upon learning of any allegations of potential caregiver misconduct, staff must take the necessary steps to protect all patients from possible subsequent incidents of mistreatment or injury by taking the following steps: 1 Take steps necessary to ensure the safety of patients...2. Any employee witnessing alleged or actual misconduct is required to report this occurrence immediately to leader or supervising authority. 3. The leader or supervising authority who becomes aware of such concerns should immediately call the Clinical Risk Management or Compliance team to receive direction on the investigation..." (This policy does not reference that a SafetyZone event report needs to be submitted regarding caregiver misconduct).

A review of the facility policy, titled "Patient Safety Event Reporting (System)," last revised 02/2023, revealed: "PURPOSE: To outline the purpose and process for reporting all patient safety incidents...Incident: Event that reaches the patient whether or not the patient was harmed...POLICY: A. A SafetyZone event report should be completed by the person who has the best knowledge of the event. This may be the person involved or the person who first discovered or became aware of the event..."

A review of the facility patient admission brochure, titled "Patient Rights and Responsibilities," reviewed 09/21, revealed: "...Patient Safety...You will be cared for in a safe environment by competent and caring doctors, nurses, and other health care staff members...You will be free from abuse, harassment, and seclusion..."

A review of the misconduct event timeline created by Clinical Risk Management D, revealed:
"7/25/2023 - Event occurred at approximately 1530 (3:30 PM) to 1630 (4:30 PM). RN [G] spoke with the managers and expressed that she felt like RN [A] did not work well with a patient. She was encouraged to provide specifics and did not. Managers asked her to enter a SafetyZone event.
7/27/2023 - Managers asked the RN [G] to enter SafetyZone event regarding concerns.
7/31/2023 - RN [G] entered the SafetyZone event at 12:30 PM. RN [G] provided more information regarding the event.
8/01/2023 - RN [A] removed from the schedule at 07:28 AM. Staff were interviewed. The misconduct review team reviewed and substantiated the event. The event was then reported to DHS at 12:00 PM.
8/03/2023 - RN [A's] employment was terminated at 11:50 AM."

During an interview on 09/26/2023 at 12:04 PM, Associate CNO B stated that she was made aware of a "concerning event" in the MSICU regarding an RN, she questioned MSICU Nurse Manager H if there was a safety event entered; MSICU Nurse Manager H was trying to connect with the nurse involved to place a safety event. CNO B stated she was then involved in the follow-up meeting with RN A after the SafteyZone was submitted by RN G on 07/31/2023. When asked CNO B what RN A's perception of the incident involving Pt. #1 was, CNO B stated, "he was remorseful, he went too far and apologized - he owned it."

During an interview on 09/26/2023 at 12:20 PM with Clinical Risk Management D, when asked what immediate action was taken once the incident was identified regarding RN A and Pt. #1, Clinical Risk D stated that once the SafetyZone report was submitted by RN G on 07/31/2023 "the seriousness was identified and RN [A] was removed from the schedule for the investigation." Clinical Risk D stated that RN [F] was another witness to the incident.

During an interview on 09/26/2023 at 2:14 PM with RN F, when asked about the interaction she witnessed between RN A and Pt. #1 on 07/25/2023, RN F stated she didn't know initially what to think, "I told (RN G) I will state what happened if she puts a report in."

During an interview on 09/26/2023 at 3:20 PM, RN G stated "I reported the incident to my manager the same day, immediately after it happened - like 10 minutes." The patient was "detoxing", patient needed an IV and I asked (RN A) to help. (RN A) was using an ultrasound to guide the IV, "the patient was screaming and yelling at us; (RN A) grabbed the patient's left shoulder, then poked his finger in the patient's rib. Both managers [Staff H & Staff N] were working this day, they told me to put in a SafetyZone that I put in after the weekend."

During an interview on 09/26/2023 at 3:39 PM with MSICU Nurse Manager H, when asked about RN [G] reporting the incident on 07/25/2023 to her, Manager H stated "RN [G] said there was a 'weird interaction' in the patient's room with RN [A] putting in an IV." RN G was "vague" when reporting the incident, "she didn't wanna tattle - that was part of the problem."

On 07/27/202, Nursing Supervisor N talked to RN G again and asked her to put in a SafetyZone; "RN [G] had a bad patient on this day, so no SafteyZone was put in. Supervisor N then sat her (RN G) down on Monday (07/31/2023) to get the SafetyZone in."

When asked if Manager H or Supervisor N interviewed RN A to ask about the 'weird interaction' that was reported by RN G during the IV insertion, Manager H stated, "no." Manager H stated that she met with Human Resources and Associate CNO B about the SafetyZone that RN G submitted, "he should have come off the schedule that night in retrospect, as the investigation went on it was apparent."

When asked how long RN A worked on the MSICU floor after the incident was reported on 07/25/2023 by RN G, Manager H stated, "He worked on the ICU floor until terminated off the schedule on 08/01/2023." Manager H stated that if she had known that RN A was "abusive" she would have sent him home and not come back the next day. Manager H stated that she did follow-up training with unit staff regarding their responsibility to submit a SafetyZone report immediately after an event/incident. When asked if RN G would have reported possible abuse or caregiver misconduct on 07/25/2023, Manager H stated she would have contacted Associate CNO B to let her know, and also Compliance to get the investigation started; "Once the SafetyZone was in, the investigation then started."

A review of MSICU staffing schedules revealed that RN A was scheduled to work (and had patient assignments) on the MSICU floor on the following dates: 07/25/2023 (7:00 AM-7:00 PM), 07/26/2023 (7:00 AM-7:00 PM), 07/28/2023 (7:00 PM-7:00 AM), 07/29/2023 (7:00 PM-7:00 AM) and 07/30/2023 (7:00 PM-7:00 AM), and was the Charge Nurse with no patient assignments on 07/31/2023 (7:00 PM-7:00 AM); RN A worked 6 shifts on the MSICU floor after the 07/25/2023 incident due to staff (RN G and RN F) not accurately and immediately reporting caregiver misconduct.

A review of "Daily Leadership Safety Huddle" meeting minutes, dated 08/02/2023, revealed: Clinical Risk Management & Patient Safety presented the "Promoting a Culture of reporting" PowerPoint education (pertaining to caregiver misconduct reporting/follow-up actions) to leaders, with the expectation that education communication will cascade from leaders to their department/unit huddles.

The facility's internal investigation and misconduct review team substantiated caregiver misconduct on 08/01/2023 regarding the incident involving RN A and Pt. #1 on 07/25/2023 on the MSICU floor. The facility's internal investigation started on 07/31/2023 (6 days after the incident), when RN G submitted a SafetyZone event report; RN A worked 6 shifts on the MSICU floor after the incident, and then was terminated from his position on 08/03/2023. After the incident, the facility conducted staff training pertaining to caregiver misconduct reporting/follow-up actions for staff in the MSICU department and for department leaders at their Daily Leadership Safety Huddle, though there was no evidence to support that all departments/units had been educated.